Provider Demographics
NPI:1184801391
Name:HERZOG, MITCHELL H (LCSW-R)
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:H
Last Name:HERZOG
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E STATE ST
Mailing Address - Street 2:STE 201
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4400
Mailing Address - Country:US
Mailing Address - Phone:607-277-7079
Mailing Address - Fax:607-257-2919
Practice Address - Street 1:401 E STATE ST
Practice Address - Street 2:STE 201
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4400
Practice Address - Country:US
Practice Address - Phone:607-277-7079
Practice Address - Fax:607-257-2919
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-0713691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical